Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
BRUKINSA 80mg Bruton's tyrosine kinase (BTK) inhibitor PA, QL 3 3 3 3 3
NAYZILAM 5mg Nasal spray ready-to-use treatment for seizure clusters PA, QL 2 2 2 2 2
NOURIANZ 20mg and 40mg Add-on therapy to treat off periods in Parkinson’s disease PA, QL 3 3 3 3 3
VUMERITY 231mg Treats relapsing forms of multiple sclerosis (MS) PA 2 2 2 2 2
WAKIX 4.45mg and 17.8mg Treats excessive daytime sleepiness in adults with narcolepsy PA, QL 3 3 3 3 3

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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